When the Therapist Falls Asleep During Session

I dozed off for about ten seconds during a session today. Over the last 30 years, this has happened to me three times that I recall. The first time was with an elderly client, benignly psychotic but disengaged from the therapeutic process; briefly dozing made me realize I’d come to feel that I couldn’t help her. The second time, I had just returned from abroad and went back to work too soon; I was jet-lagged and nodded off during what would have been night in my former time zone. Today, it happened with a client of long-standing. I’d finished another session immediately before this one and did not feel tired. It was mid-day and I’d slept reasonably well the night before. Just prior to my eyes closing, my client had told me she was feeling so tired she just wanted to drop off, fall to the ground and go to sleep.

I’ve experienced this kind of sleepiness before, with several different clients — a sudden, out-of-the-blue feeling that my eyelids are so heavy I can’t keep them open. (I’ve also felt tired on many other occasions — my own fatigue, from stress or too little sleep the night before — but not dozed off.) Usually I’m able to tell the difference between them, whether it’s my own exhaustion or a … well, a kind of communication. On the woo-woo scale of things, I’m fairly skeptical, but I do believe in something like ESP — a capacity to perceive through a sensory apparatus other than one of the five usual suspects. I believe good therapists are highly sensitive in this area. In broad terms, you might think of it as a kind of countertransference response or a form of empathy.

The usual metaphor used to describe empathy is “putting yourself in someone else’s shoes,” which implies that the person who empathizes actively does something to identify with the other person, going outside of him- or herself into the other. I prefer to think in terms of a sponge, where the empathizer absorbs a portion of the other person’s emotional experience — say, his suffering. At the same time, the person suffering may project her pain as an unconscious kind of communication. I find that I often “tune in” to the very feelings my clients need (but can’t seem) to feel.

I worked for a number of years with a young man in his twenties whose father had been very strict and authoritarian. Tim was detached from his feelings most of the time and I found it hard to make emotional contact with him. During many sessions, as I was sitting in my chair behind the couch upon which he silently lay — in other words, where I couldn’t see his face or read his expressions — I would feel a wave of sadness come over me. Tim had said nothing for several minutes beforehand. I’d feel an ache in my chest and at the back of my throat; my eyes would well up with tears. Experience had taught me that asking him “What are you feeling?” would get us nowhere. Instead, I’d ask him to direct his attention to those same places — his eyes, his chest, his throat — and describe his sensations. Most times, this helped him connect with his sadness, though it remained very difficult to understand the meaning of it.

With another client, I used to feel my face going numb, as if my head were being subjected to enormous pressure. This led us to some pretty interesting fantasies about her birth. On occasion, I’ve felt physically aroused and puzzled, just before an embarrassed client finally admitted to a sexual fantasy about me. We therapists don’t usually talk about these things, either because they make us appear wacky or because it sounds unprofessional when a therapist admits to having sexual feelings during session. Just for the record, I have never felt even slightly tempted to act on those feelings. I’ve always understood them as some kind of unconscious communication.

In session today, my client immediately understood that my sleepiness had something to do with her own experience. I told her that I hadn’t been feeling tired before session, but that I’d been fighting to keep my eyes open for several minutes before they actually closed. As soon as we began to discuss the “soporific” way she’d been talking beforehand, we both felt much more alert, suddenly wide awake. I doubt we completely understood what happened, but we were able to link our sleepiness to her fear of having distinct opinions and voicing them (as seen in material from earlier in the session), along with the anxiety she felt about being perceived by others as competent, even an authority. Coming into her own — waking up to herself, as it were — feels dangerous for all sorts of reasons; she’d prefer to fall back asleep.

During sessions with clients over the years, I’ve felt many different ways — angry, resentful even envious — but I could usually link it to the verbal material — words actually said or expressive tones of voice. The more fascinating experience, much harder to explain, is the one that emerges from silence, without words or visual cues to account for it. As a therapist, you have to be a bit skeptical; you can’t assume that everything you feel in this way is a kind of projection from your client. But if you exercise caution, this mysterious kind of empathy can prove a useful addition to your clinical toolkit.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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43 comments

    Okay. This is not germane to the issue of falling asleep (which I’m glad didn’t happen during a session with me were I your patient, because I’d just get up and slip quietly out of the room if you were so whatever that you drifted off to dream, but I’m just sayin’…). Also, maybe the patient’s soporific sense was the patient picking up your tiredness, as much as it was the reverse. Again, I’m just sayin….

    But maybe you can talk about the physical positioning of the couch in another blog post? Because I’m sort of amazed that you sit where you can’t even see a client’s face during the session, to read their expressions. Is this typical of analysts? What’s the point of the client even being in the room with you, then? You may as well both be blind. What is the ulility of not being able to get the subtext of a person’s eyes, the purse of their lips, the momentary flicker as they look away, or toward the sky — facial gestures that might belie what they’re saying, or give additional insight? I imagine you could be positioned so you could see the patient, but the patient couldn’t see you. Wouldn’t that give you more information?

    Like I said. Not at all on point. But that’s what your post got me thinking of.

    The questions come with their own answers. “You may as well both be blind.” The position of the analyst’s chair behind the couch has been standard operating procedure since Freud starting working psychoanalytically more than 100 years ago.

    I’m now curious as to how you work via Skype. Do you use the video facility, or is it just voice? Like the other reader, I had always assumed you sat opposite your patient, face to face. This is really interesting!

    These days, I work mostly face-to-face via Skype. I sat behind the couch when I was doing more intensive work — three or four sessions per week. Most of my practice now is once or twice a week.

    It may be material for another thread, but which one makes a better connection with your patients? Behind them, or face to face?

    I think there’s something to be said for both modes. Face to face, as you pointed out in your earlier comment, gives you the opportunity to read all those non-verbal cues. At the same, it imposes a certain restraint on the therapist. For me, I am always conscious that my clients are watching me and likely trying to read my expressions for information about what I “really” feel. I find it a kind of relief to sit behind a client and focus on my own process, listening intently with no concerns about what my face might be saying.

    The “woo woo scale of things” – that has gone to the top of my list of awesome descriptors :)

    This post has that effect for me, too. All sorts of stuff going on, I suppose, in that it helps me feel like maybe my therapist too is really a person, feels things about me. Your blog seems to help me engage better in my own therapy, be a bit braver about being vulnerable.

    Now – if I could just get my therapist to fall asleep when I would rather have him be less focused…

    Do you ever think maybe the sleepiness may come as a defense mechanism against the client making you feel something you don’t want to feel? I ask because I realized about myself that when I fall asleep at times where I was sure I wasn’t tired, it was usually a result of being uncomfortable with something someone was telling me.

    It’s a question any therapist working with his or her countertransference (in the broad sense) must ask himself when such feelings come up.

    As a Dramatherapist, who often works with non verbal clients, your post really resonated with me. I find being aware of how I am physically feeling within sessions can sometimes bring me closer to the experience of a client.

    It helps to be in touch with your own physical sensations — I mean, on a regular basis. Don’t you think?

    Very much enjoyed the article Joseph. I don’t think there is anything woo-woo about what you describe. Some of us are better at picking up signals than others, that’s all. Besides, way back in time, and before “civilization” dampened down valuable instincts, humans had to depend on those senses in order to survive. We’ve probably all had our hair stand on end (the hackles rising), or maybe you are somewhere and turn without realising as you know you are being watched or stared at. Then there are people who leave you feeling drained, although you are not sure why. There are others where you want to fling open all the doors and windows after they have left the house, but you are not sure why. I know a few people where I want to fall asleep after a few minutes in their company.
    IMO what we call sixth sense is what our long-ago ancestors had, and we still have it if we listened to it.

    Hermes

    My therapist often yawns during sessions and it really bothers me. A few times it’s looked as if he was about to fall asleep. It’s usually during sessions at the end of the week when he’s probably tired, but it still bothers me because I have never once yawned in the 4 years I’ve been seeing him.

    We’ve talked about this a few times. I came right out and told him that it really bothers me when I see him attempting to stifle a yawn and that I would prefer it if he’d just tell me that he was very tired and might yawn once or twice during the session instead of trying to hide it. He didn’t really respond one way or the other and he still yawns occasionally. And it still bothers me.

    That would bother me, too. It may be that your therapist is working too hard. Sometimes that kind of fatigue is a sign that we’ve taken on more than we can handle emotionally. I think that yawning or, even worse, nodding off during a session would be terribly hurtful to most clients — as if the therapist is saying, “You don’t interest me.” When you’re sharing your most painful feelings with someone, to be met with indifference or boredom would be irritating, at the very least.

    What I hoped to make clear in my post is that this nodding off is an extremely rare occurrence for me and, to the best of my knowledge, had nothing to do with my personal state of mind or feelings for this particular client. I almost never feel sleepy during session, but as I thought about it further, I have frequently felt sleepy with this particular client over the last two months. Something is going on I don’t fully understand yet, but I’m fairly clear that this is not about me or my feelings for her.

    This sounds odd – you rarely feel sleepy to the point of falling asleep in sessions, yet you do regularly, recently, exceptionally, with this client. And you think this is not about your feelings about the client? If it’s something this particular person, or your interaction with her, provokes in you, is this not precisely about your feelings about her?

    Yes, but why do I have those particular feelings? I’ve subsequently done a little experiment. I decided that the next time I began to feel sleepy, I would tell her. Just as I was about to do so, she told me she had been feeling very tired for the last few minutes and could barely keep her eyes open. What interests me is how that was communicated to me, and what it means.

    Ok, but seems like you’re getting hung up on “how it was communicated,” which seems to be really a fairly simple function of being in tune with someone as a result of an extended interaction. “What it means” seems to have become a bit neglected, in the shadow of this cool and interesting process of communication. Would love to hear more about this part of it.

    I think I’m going to leave this subject alone for now. It seems that many readers have had a hard time with it; I’ve had several suggestions for what really happened, so obviously, I’m not communicating very well.

    It does not sound woo to me, you’re just more sensitive than other people. As we all know animals are much more sensitive to nonverbal communication,too, yet no one thinks that’s woo. But we are also animals with varying degrees of perception and sensitivity.

    I hadn’t thought about it that way. If I think about what my dog “senses” that I don’t, what she can feel way before I do, you’re right — no one thinks of that as “woo woo.” Thanks.

    A monotone could put you to sleep. Thank goodness that’s never happened behind the wheel.
    Two things I’ve never done are pass out or fall asleep except in bed. Never fallen asleep on a plane. The mind is too busy I suppose. Drink a lot of water.

    Oh, the busy busy mind that won’t let you fall sleep. I’ve slept on planes but only with the help of Dalmane.

    Talking about therapist’s falling asleep during session – has anyone had one late for their appointment because they fell asleep in their office? That happened to me.

    This psychologist acknowledged that I was there and said he would be right with me. 20 minutes later his receptionist phoned him, no reply, then went and knocked on his door. It was a really bad moment for me as I was feeling suicidal at the time – so I felt particularly angry with him for this.

    Another therapist, more recently had a tendency to nod off in the late afternoon, however, I would not take offense to this as he has MS and I knew that it wasn’t a lack of interest or distrespect that was causing his eyes to close. I would jokingly call his name and bring him back to the conversation and laugh and say that he needed a bigger coffee.

    I admire your understanding. I think most clients would find it unbearably painful for their therapist to fall asleep during a session. Fortunately, the client I described in this post has been with me many years and understood, as well as I did, that my nodding at that moment “meant something” … (i.e., it didn’t mean that I was bored or indifferent).

    I enjoyed this post. Thank you for your openness. After being in psychodynamic therapy with the same therapist for many years, it is nice to get a glimpse into a therapist’s perspective. I often struggle with why my therapist’s views and feelings are veiled so heavily. I understand the basic concept but it seems like over kill at times. Maybe I just don’t like the feelings that this “veil” brings up in me?

    I understand. Over time, I’ve become more relaxed about revealing what I feel. I still tend more to the neutral side, but I don’t think my clients have much doubt that I care about them, or that I feel for them when they suffer.

    Another really insightful post.

    My therapist has yawned many times in session, often after I’ve yawned (they’re catchy). We talked about it at one point. Sometimes a yawn is just a yawn. 😉

    But it’s great to dig down and find these deeper meanings, when they’re there.

    Very interesting comments! I don’t get the “psychoanalysm” of sitting behind a couch where the therapist is not visible. The eyes are the window to the soul (I strongly believe!). Once I went into session with one of my psychiatrists who had a bluetooth thing hanging off his ear. He actually interrupted our session to make dinner plans! I promptly told him I thought that was unprofessional and rude. He agreed, apologized and I never saw it on him again! (I have fired therapists for things like this – and maybe I was too quick to judge). I currently have a psychologist who has several times lately excused himself saying he had to get up and stretch. He went into what I called excessive gyrations (not just little stretches to get rid of kinks or a refresher), but yawning, rocking side to side and twisting around and around. I found it EXTREMELY distracting and would forget my train of thought. Perhaps that was his modus operandus? Then one day we decided to hypnotize me. After about 10 minutes he stopped the session and confessed that he had nearly hypnotized himself. Needless to say, I was still wide awake although I gave it the “old college try”. What’s up with that? Seems to me if he were good at hypnotizing he would be immune – or perhaps he did it to trick me. I don’t know although I suspect it would take a VERY good and experienced hypnotist to put me under. Maybe there’s a connection between my unsusceptibility and my devastating insomnia (my personal record is 5 nights and 4 days w/o sleep or even a nodding off) and no, I’m not on any kind of meds that would trigger this. It has been an ongoing problem for me for years. I’m looking forward to my “sleep study” to be done soon. Do any of you see any relationships among these and what has been talked about? Thanks!

    Often when I am having a really intense listening or concentrating experience I find I hold my breath…when a natural break in the phrase arises I will gasp for breath or yawn as it may appear. For me, the yawn is far from an indication of bordom or disinterest, it means I’m really into what my partner in conversation is saying.

    Interesting. My daughter told me yesterday that humans yawn in order to sharpen their attention, not necessarily because they’re bored or disinterested.

    Once or twice in therapy sessions, when the therapist and I were communicating about really difficult things (repressed trauma), the lights in the room would flicker intensely. I have always understood (not scientifically, just personally) that the repressed trauma causes different electrical reactions in my body, because I will blow lightbulbs and short electrical appliances just by touching them prior to flashbacks. I like to think of it as the neurons racing around the ‘hole’ of the trauma in my brain, trying to reconnect but sort of sizzling off of the hole! It does make sense to me that if I am in a space where this is being shared e.g. therapy, then the other person/ things in the room are likely to experience it too.

    Truly fascinating. As I said, I’m fairly skeptical about many things but this sounds like there might one day turn out to be an entirely plausible scientific explanation.

    Perhaps it’s just that not enough is researched into the Circadian rhythm? Maybe that’s a topic, Joseph, for another day.
    As a night person, and it must be genetic, as my Dad was a night person too, one finds that sometimes the “larks” who get up at an ungodly hour look at us owls askance. L.
    Fortunately, I work for myself, and I find my brain does its best work late in the evening/night. So I don’t have to adhere to culturally imposed rising timetables.
    The Music of the Night is indeed sweet. !

    “Yet Brown and Arand believe that one’s unavoidable preference for morning or evening should not be considered bad or unhealthy. Society, they agree, should be more accepting of inherent sleep-and-wake modes, particularly of night owls, for whom adhering to standard business hours is arduous.

    “We know sleep is not a bad habit,” Brown said. “It can’t be kicked.”

    From: http://www.livescience.com/16334-night-owls-early-birds-sleep-cycles.html

    Best regards,
    Hermes

    It seems that many people have had trouble with this post. Both my client and I felt absolutely clear that the sleepiness had to do with a therapeutic dynamic, and yet several readers have offered a different explanation (as if they know better than the people who were in the room), or to use it as a launching pad to discuss some tangential subject.

    Well once again a fascinating post with many fascinating responses. I too am a behind the couch therapist. I also see people face to face within another setting. The sleepiness I have when I am genuinely tired is completely different from the countertransferential sleepiness I have experienced over the years. I can jolt myself out of tiredness when I have not slept or dropped someone at the airport at 5 am ( never did that again when I realised the impact it had on my work ) but the sleepiness I have experienced within a therapy session has been unrelated to my feelings about that particular patient. The most powerful, CANNOT keep lids up feeling was once explored directly within a session. The patient told me, when I remarked upon it, that she had noticed I went sleepy when she was ‘ lying’ about something. This opened a vein of work which we are still working on together three years later. She is diligent and committed to therapy. She has lost over 50 lbs, coloured her hair, and is now dating….so something has shifted. I feel enormous compassion and respect for her despite my sleepiness. I have learnt a lot from her over these years. I feel privileged to be her therapist.

    Maybe it takes another therapist to understand what I’ve been trying to write about — thanks, Lola. Your description of your own sleepiness is exactly the thing I’m trying to talk about, and I find the link you make to your client’s “lying” to be fascinating. I think Bion would have agreed with your assessment and applauded the way you made use of that insight to further your understanding of this particular client.

    I think it is demons having their fun. It is easy for them to cause sleepiness and sexual arousal, and they enjoy doing it, especially the sexual arousal. It is icing on the cake if they can get you to think that you are telepathic or developing some extrasensory abilities. They love the smell of human pride… and they do enjoy messing with therapists, since they like messing with the mind – deceiving people…

    Anyway, thank you for the video of the narcissist/psychopath from Facebook. The n/p I knew best would never permit himself to show disrespect or anger. That didn’t fit his “image,” [or is “act” more accurate?]; he was passive-aggressive instead. So I’m glad to have the example of Mark Z. He is different. I never joined facebook, now I have another reason why not to…

    This is really interesting because it taps into our physical interactivity with interpersonal process. It can be quite visceral. As a new therapist, I once had a yawning/want to doze reaction to a learning-disabled child, and after some self doubts, figured out the resistance. It took some time, and I had tried to alter the dynamic using play therapy, but the child did not really want to play. The child wanted to sit and speak about her memories of the current day (a now safe topic). In a complex family dynamic, this child was playing the part of the protected child who did not know about extreme abuse going on in the family. When asked whether she knew a lot more about what was going on in her family than she was saying, she slyly looked to the side and nodded. She was protecting her mother who was in denial about knowledge prior to the revelation of the victim. This little child was not talking until the mom was ready. She was protecting her family integrity as best she could.
    I have seen chronic yawning (and yes, this is infectious to a humorous extent) in clients who are resisting, and shuddering yawns in clients who are letting go of internalized tensions. I found it more frequently in jails and prisons.

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